MEDICARE: CONCOURSE SURGICAL SPORT SUPPLY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912910571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCOURSE SURGICAL SPORT SUPPLY, INC.

Provider Business Mailing Address
First Line	:	8 EDGEWOOD DR
Second Line	:
City	:	ORANGEBURG
State	:	NY
Zip	:	10962-1604
Country	:	US
Telephone Number	:	212-569-2635
Fax Number	:	212-569-2639

Provider Business Practice Location Address
First Line	:	5049 BROADWAY
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10034-1131
Country	:	US
Telephone Number	:	212-569-2635
Fax Number	:	212-569-2639

Authorized Official
Title or Position	:	MANAGER
Name	:	NIDIA PENA
Credential	:
Telephone Number	:	212-569-2635

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	10/05/2020

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